Purpose: To investigate the mode of presentation, management and outcome of ischaemic contracture following a supracondylar fracture with a pink, pulseless hand. Methods: We reviewed the database at our tertiary referral unit to identify cases over a 20 year period who had been referred for complications of a supracondylar fracture and/or a Volkmann’s ischaemic contracture. Results: We identified 20 children with Volkmann’s ischaemic contracture following a supracondylar fracture. Of these, 4 patients (mean age 5, range 2–11) were referred to us with evidence of an ischaemic contracture but they had always had a pink albeit pulseless hand. Two of these 4 had undergone vascular exploration at 48 hours and at 72 hours but despite this developed an ischaemic contracture. The 2 patients with the most severe contractures have undergone surgical intervention for their contracture, and 2 were managed conservatively with splinting. All 4 cases have residual problems with hand function (mean follow-up 5.5 years, range 2–11). Conclusions: Volkmann’s ischaemic contracture should be a preventable condition. The pink albeit pulseless hand is at increased risk of ischaemic muscle and nerve damage and should not be ignored as the consequences are potentially devastating. Significance: Clinicians must consider whether they feel that their management protocols for the pink, pulseless hand are robust and defensible.
Traction lesions of the brachial plexus are severe and disabling. All too often the patient is young, and many will be unable to return to work. Diagnosis has become more precise with the introduction of CT, with contrast, of the cervical spine, and the detection of cortical-evoked responses at operation.
To review the outcome of compound injury to the shoulder in which traumatic anterior dislocation is associated with concomitant rotator cuff tear and injury to the brachial plexus. 22 patients initially treated at the Peripheral Nerve Injury Unit since 1994 were reviewed from notes, telephone and clinically (n=13) where possible. 19 men and 3 women of average age 53 years were treated with a minimum 3-year follow up. All patients underwent exploration of the brachial plexus and nerve repair where required (graft n=5). Patients had either proven large cuff tear (n=13) or avulsion fracture of greater tuberosity with cuff injury (n=9). 7 of 13 cuff injuries and 7 of 9 tuberosity fractures had been repaired. Nerve injury at exploration was to circumflex (n=20), supra-scapular (n=12), musculocutaneous (n=6), or at the cord level (Posterior n=10, Lateral n=7 Medial n=8). Outcome measures were Berman pain score, sensation, muscle power (MRC grade), abduction, functional scores (Mallett and DASH) and return to work. Statistical analysis used tests for non-parametric data. 22 patients had exploration of the plexus. Most patients did not have an isolated nerve lesion (n=4). Increased depth of nerve lesion correlated with poorer functional outcome. E.g. for circumflex nerve injury (n=18), conduction block (n=8) vs. axonotmesis or neurotmesis (n =10) functional range of movement as assessed by Mallett score was significantly different; Mann Whitney U test p=0.043. Late exploration of nerve tended to correlate with poor outcome, as did late repair of rotator cuff, but not to statistical significance. Our explorations have shown the nerve injury sustained in these patients to be more widespread than expected. We believe early exploration is vital to give an accurate diagnosis and predict outcome for the nerve lesion. This is particularly important in the presence of associated cuff injury where early repair confers favourable outcome.
Forty-three cases of accessory nerve injury referred to the Peripheral Nerve Injury Unit have been reviewed. Accessory nerve injury results in a characteristic group of symptoms and signs. Referral for treatment is usually delayed, the average time being 11.3 months. Surgical treatment resulted in improvement of symptoms in almost all cases.
We used freeze-thawed muscle grafts to restore continuity to the affected nerve in 22 painful cutaneous neuromas. In 11 of the 15 neuromas in the upper limb, pain was partially or completely relieved; in six of these there was some recovery of distal sensation. Partial pain relief was achieved in only two of the seven neuromas in the lower limb. The difference is attributed to the longer grafts required in the lower limb.
A schwannoma is a benign nerve sheath tumour originating from schwann cells. It is the most commonly occurring peripheral nerve sheath tumour. The common sites of occurrence are the head and neck followed by the upper and lower limbs. Diagnosis is straightforward and is made clinically. Schwannomas of the tibial nerve pose a problem. The literature describes them as causes of chronic, intractable lower limb pain because their diagnosis is often delayed for several years. The main reason postulated is that a lump is not always palpable in the early phases and hence chronic cramping pain in the calf or foot is attributed to lumbosacral radiculopathy or local neuropathy. We report the largest case series of twenty-five patients diagnosed with a tibial nerve schwannoma. Only three cases were diagnosed within a year of initial presentation. The mean time to diagnosis was eighty-six months. The most common site of pain was the sole of the foot (eighteen cases). A Tinel9s sign was elicited in nineteen cases. MRI confirmed the diagnosis in all the twenty cases where it was performed. Surgical resection was performed in all cases yielding excellent results. Only one patient required further neurolysis for persisting pain. In patients with a long history of neuropathic lower limb pain, where lumbar and pelvic lesions have been excluded, a high index of suspicion should be maintained for a peripheral nerve tumour. Delay in diagnosis is commonly due to lack of familiarity with peripheral nerve pathology and the absence of a palpable lump. The delay can result in numerous unnecessary medical and surgical interventions in this group of distressed patients. The Tinel9s sign is the key to identifying a tumour of neural origin in the absence of a palpable lump. Surgical resection of the tumour remains safe and effective in providing symptomatic relief.
In a recently published article I have suggested an amendment of the textual crux in Suetonius, Tiberius 21. 4 and an interpretation of the passage as providing direct evidence that the arrangement of the marriages of Germanicus and the younger Drusus was integral to Augustus' settlement of 26 June a.d. 4, even if (as seems on balance likely) they were not celebrated until early 5. This view differs from the more usual assumption that while the marriages took place in 5, the date of their arrangement was not particularly significant, or from the possibility implied by Levick that Germanicus' marriage may have been arranged to placate the ‘faction’ (or what remained of it) of the elder Julia after the consolidation in 4 of the position of Livia's descendants. The more precise hypothesis that the marriages were intended as part of the settlement may help us to bring into sharper focus some of the political events of the next few years, and this article attempts to do so; in particular it looks at ( a ) the internal balance of the settlement; ( b ) the anomalous separate adoption of Agrippa Postumus; and ( c ) the decline and fall of Agrippa Postumus and the younger Julia. First, however, some further observations on the hypothesis in my earlier article.
The achievement of independent mobility by children with spina bifida is often hampered by deformities of the knee joints. This report reviews the results of surgical treatment in 34 spina-bifida children with knee deformities. The surgical procedures are described and it is concluded that surgery is justified in a proportion of cases with fixed-knee deformities.
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